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Pediatric recurrent abdominal pain is commonly associated with negative impacts on quality of life (QOL). Positive schemas (core beliefs about the self with subthemes of self-efficacy, optimism, trust, success, and worthiness) are a resilience factor that has not yet been examined within a pediatric recurrent pain context. This cross-sectional study examined (a) associations between positive schemas, pain coping, and youth QOL, and (b) exploratory analyses to investigate whether specific positive schema subthemes predicted QOL outcomes in youth with recurrent abdominal pain. Participants were 98 youth with recurrent abdominal pain (i.e., pain related to a disorder of gut-brain interaction [DGBI] or organic cause) who completed measures on positive schemas, QOL, and pain coping. Age and diagnostic status were controlled for in analyses. Positive schemas were significantly positively correlated with emotional, social, school, and overall QOL, as well as with approach and problem-focused avoidant coping, and significantly negatively correlated with emotion-focused coping. Worthiness was the strongest and only significant predictor of youth social functioning. Positive schemas may be an important cognitive resilience factor to consider within interventions for pediatric recurrent pain.

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Chilaiditi sign is defined as the interposition of the colon or small intestine between the liver and the right diaphragm in the absence of symptoms. Chilaiditi syndrome refers to the condition where the Chilaiditi sign is associated with symptoms including abdominal pain. In this series, we present the cases of two pre-pubescent patients with these rare conditions.  A 10-year-old female with a history of autism, IgA deficiency, and constipation presented for gastrointestinal studies due to weight loss and constipation. An abdominal X-ray revealed bowel gas under the right hemidiaphragm and colonic interposition between the diaphragm and the liver, raising concerns for the Chilaiditi sign. She underwent a bowel cleanout, with studies revealing colonic dysmotility and compartmentalization of the sigmoid colon and rectum with the absence of coloanal reflex. A nine-year-old female with a history of constipation, developmental delay, and hypotonia presented with abdominal pain, vomiting, constipation, and decreased appetite. She also manifested tachypnea, abdominal distension, and abdominal tenderness, with an abdominal X-ray revealing a dilated colon interposed between the liver and diaphragm, confirming Chilaiditi syndrome. Prior gastrointestinal studies showed dilated and redundant sigmoid colon and dyssynergia. The treatment entailed rectal irrigations and catheter decompression, which led to the improvement of symptoms. Conservative treatment is the treatment of choice for patients with Chilaiditi sign or Chilaiditi syndrome. It is important to distinguish Chilaiditi syndrome, a common cause of pseudo-pneumoperitoneum, from true pneumoperitoneum, as this diagnosis warrants immediate surgical intervention. Surgical treatment is indicated when there are signs of bowel obstruction or ischemia and for cases with recurrent Chilaiditi syndrome. Raising awareness about this condition is important to reduce the incidence of misdiagnosed surgical emergencies and resulting exploratory surgeries, as well as to avoid high-risk colonoscopies. Chilaiditi sign and Chilaiditi syndrome are relatively uncommon entities, and their prevalence is very rare in the pediatric population. Hence, we believe this case series will contribute to providing clinical awareness of these major complications and avoiding invasive interventions due to the inaccurate diagnosis of these conditions as pneumoperitoneum.

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Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Important considerations in the selection of a diagnostic imaging strategy include the sequencing, performance, and cost of tests. This article provides a comprehensive narrative review of the diagnostic imaging of RLQ pain in children and adolescents, including a discussion of the complementary roles of ultrasound, CT, and MRI; description of key imaging findings based on available evidence; and presentation of salient differential diagnoses. Subspecialized pediatric emergency medicine and surgical perspectives are also provided as further clinical insight into this common, but often challenging, scenario. Finally, the current status of imaging of RLQ pain in children and adolescents is summarized on the basis of expert consensus.

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The swallowed or aspirated foreign body is a common pediatric emergency medicine complaint for which emergency providers must be familiar with the intricacies of management. Most swallowed foreign bodies will harmlessly pass through the GI tract, but children with GI tract abnormalities may have an increased risk of object impaction. There are few reported cases of foreign object ingestion in children with GI tract abnormalities, specifically ostomies. The Foley catheter is a versatile tool that is easily accessible in the ED setting. We present a novel case of foreign body ingestion in an infant with a colostomy secondary to Hirschsprung's disease managed with Foley catheter retrieval through an ileostomy stoma. A 17-month-old infant presented to the ED with a chief complaint of an episode of bloody vomiting. He had a two-day history of increased irritability and intolerance of feeds with emesis after every feed. The child's medical history is pertinent for Hirschsprung's disease, for which the patient had a pull-through procedure shortly after birth and a revision of the pull-through. On physical examination, the patient's ostomy was found to contain brown-green liquid stool. A small ovular mass was visualized at the stoma during crying episodes. Supine posteroanterior radiograph of the abdomen showed an oval-shaped radiolucency consistent with a metallic ingested foreign body at the site of the stoma. The foreign object was removed using a Foley catheter and forceps and was found to be a penny. The patient was observed and discharged without complications later that day. Treatment of a symptomatic ingested foreign object requires careful consideration of the type of object present and its location in the body. In this case report, we discussed the removal of an ingested coin in a symptomatic 17-month-old infant with a history of ileostomy secondary to Hirschsprung's disease using a Foley catheter. In children with ostomies, prompt imaging and non-surgical removal may be an option to manage retrieval of these objects if the patient is stable and symptoms are not severe.

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Evaluation of undifferentiated pediatric abdominal pain presents a unique set of challenges, especially in the setting of inconclusive and limited diagnostic imaging. In this case report, a female child presented to the emergency department with persistent abdominal pain, normal lab studies, and unusual trans-abdominal pelvic ultrasound findings. Urgent exploratory laparoscopy was completed, demonstrating a torsed adnexa rotated around a very large, mature teratoma, with irregular masses consistent with fully developed teeth. Early recognition of atypical pediatric abdominal pain in the setting of equivocal diagnostic imaging findings and collaboration with surgical colleagues resulted in a positive outcome for this patient.

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OBJECTIVE: Pediatric abdominal pain is commonly evaluated in the emergency department (ED) initially by ultrasonography (U/S). Radiology reports often include commentary about U/S limitations and possible need for additional testing or evaluation independent of study interpretation. We sought to determine if presence of a "disclaimer" is associated with additional imaging. METHODS: Design: Retrospective cohort. SETTING: Community ED with volume of 85,000 annual visits. POPULATION: Consecutive ED patients <21-years-old with appendix U/S over 12-months. Radiologist reports were assessed for disclaimers and if definitive diagnoses of appendicitis were made. The incidence of subsequent CT imaging was determined and group differences between categories were calculated. RESULTS: 441 eligible patients were identified with average age 11.7years. Of all U/S studies, 26% were definitive for appendicitis and 74% were non-definitive. Disclaimers were included on 60% of all studies, including 13% of definitive studies and 76% of non-definitive studies. 25% of all studies including a disclaimer had follow-up CT versus 10% of studies without a disclaimer (15% difference; 95% CI: 9-21). For patients with definitive interpretations, 6% had follow-up CT with no significant difference between groups with or without a disclaimer. For patients with non-definitive studies, 26% with a disclaimer had follow-up CT scans versus 13% without a disclaimer (13% difference; 95% CI: 4-22). CONCLUSIONS: Appendix ultrasound interpretations often include a disclaimer, which leads to a 150% increase in follow-up CT imaging. We suggest that radiologists consider the impact of including such a disclaimer, knowing that this may contribute to possible unnecessary imaging.

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Abstract A 2-year-old Brazilian female child from the countryside in Bahia State presented with pain in the right flank of the abdomen, accompanied by a daily fever for about 2 weeks before admission. A large mass in the abdomen was resected by the surgical team. The biopsies revealed the mass was an intra-abdominal mucormycosis. However, the diagnosis was late, and despite treatment (amphotericin B) initiation, the patient eventually died.

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